Basic Information
| Provider Information | |||||||||
| NPI: | 1285620781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULAWA | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37087 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286875616 | ||||||||
| FaxNumber: | 8286508076 | ||||||||
| Practice Location | |||||||||
| Address1: | 438 E VANN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377437202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232781704 | ||||||||
| FaxNumber: | 4232781886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 191942 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1532375 | 05 | TN | MEDICAID | P01225987 | 01 | TN | RAILROAD MEDICARE | OTHER | 4356397 | 01 | TN | BCBST | OTHER | 1532375 | 01 | TN | BLUECARE | OTHER | 01452991 | 05 | NY | MEDICAID |